Comment on the article about safety of blind percutaneous liver biopsy in obese children.

To the Editor: We read with great interest the article by Harwood et al published in issue 10 of J Clin Gastroenterol 2010. Authors retrospectively analyzed the results of 107 blind percutaneous liver biopsies (PLB) and compared their results in obese and nonobese children. They concluded that blind PLB could be safely carried out in obese children with no increase in complication rate compared with nonobese children. Similarly, there was no difference in number of passes, biopsy size, portal triads per biopsy, or biopsy success in obese children. However, there are several important points that need to be addressed. From our point of view, after a long experience in performing ultrasound (US) guidance PLB, we believe that direct US control of the needle pathway during the procedure represents the guarantee that hepatic fragment obtained by PLB is adequate for histologic analysis and additionally reduces complication rates. Several studies showed that complications appeared more often in “blind” than in “US-guided” biopsies. In this study, authors have presented similar statements in discussion section. In a prospective study, Riley reported that US examination before the PLB forced a change of the site of biopsy in 15.1% of the cases because of interposition of lung, gallbladder, large central vessel, ascites, colonic loop, and slim liver edge. Our main concern is based on the question whether blind biopsy (especially in children) would be ethical nowadays, with extensive use of US. Above all, many physicians consider US “the stethoscope of 21st century”. The opinion that the blind method of PLB (without visual inspection of the needle pathway) has the same chances for successful outcome is simply not realistic (especially regarding safety of the intervention and its complication rate). Therefore, we believe that blind biopsy is to a certain degree acceptable for clinicians (gastroenterologists/hepatologists) in the countries where only radiologists are allowed to perform US examination. In the countries where clinicians do perform US examination, we cannot recommend blind biopsy as US-guided method is likely to reduce the risk of complications and improves the quality of specimens obtained, as recommended by the American Association for the Study of Liver Diseases guidelines.